UWL Pelvis Lab

Plan 1: Calculate the single PA field.

 Describe the isodose distribution.
o For a single PA beam, the isodose lines (IDLs) demonstrate how the dose travels from
posterior to anterior before falling off gradually due to attenuation effects and increased
distance.
o IDL 100% extends anteriorly to isocenter because the treatment planning system (TPS)
automatically prescribes 100% of the dose to isocenter.
o For the 6 MV PA beam, the 110% volume of 2961.68 cc in patient’s posterior aspect is
due to the depth from the patient’s body surface to isocenter being 11.67 cm.
o The volume of the high-percentage IDLs do not provide sufficient coverage to the
planning target volume (PTV) because only 49.35 % of the PTV is receiving 100% of the
dose and 68.37% of the PTV is receiving 90% of the dose.
 Where is the hot spot and what is it?
o The hot spot is located in the superior aspect of the field at a depth of 1.24 cm from the
patient’s posterior skin surface where the beam is entering.
o Global maximum dose of 170.6% (7675.0 cGy)
 Prescription is 45 Gy in 25 fractions to the PTV
 What do you think creates the hot spot in this location?
o Physics of the buildup region between the surface and depth of maximum dose (Dmax).
The Dmax of a 6 MV beam is 1.5cm in a water phantom, and the hot spot of this plan is
within the buildup region, located superior of the field at a depth of 1.24 cm from the
patient’s posterior skin surface where the beam is entering. The Dmax of this plan
differs from the Dmax of a 6 MV beam in a water phantom because the composition of
the patient’s body and immobilization device affects beam penetration as well as scatter
characteristics.
o The proximity of the PA beam from the patient’s body to isocenter, located 11.67 cm
from the patient’s posterior skin surface where the beam is entering.
 Using your DVH, what percent of the PTV is receiving 100% of the dose?
o 49.35% of the PTV volume is receiving 100% of the prescription dose.
Plan 2: Change the PA field to a higher energy and calculate the dose.
 Describe how the isodose distribution changed and why?
The 15 MV plan (plan #2) had a lower global maximum dose of 151.6% (6823.9 cGy) and
reduced 110% volume of 2889.38 cc due to the difference of Dmax characteristics
between the two energies. The Dmax of a 15 MV beam is 3.0 cm in a water phantom.
The plan’s max dose is 2.20 cm from the patient’s posterior skin surface where the
 beam is entering, within the buildup region, and in the superior aspect of the treatment
field.
o Plan #2 had greater penetrating power evidenced by 55.10% of the PTV receiving 100%
of the dose and 78.18% of the PTV receiving 90% of the dose. The 70% and 50% IDLs
extend to patient’s bowel in the anterior aspect because percentage depth dose (PDD)
increases with beam energy and higher energies deliver a higher-percentage depth
dose. Dose at greater depths falls off gradually due to attenuation effects and increased
distance.
 Using your DVH, what percentage of the PTV is receiving 100% of the prescription dose?
o 55.10% of the PTV volume is receiving 100% of the prescription dose.

Plan 3: Insert a left lateral field with a 1cm margin around the PTV. Copy and oppose the left lateral field
to create a right lateral field. Use the lowest beam energy available for all 3 fields. Calculate the dose
and apply equal weighting to all 3 fields.
 Describe the isodose distribution. What change did you notice?
o The beams have equally distributed weighting (33.3% per field) totaling 100% to the
plan’s isocenter. As a result, there is 529.42 cc of 110% on the patient’s posterior aspect
 due to the overlap of all three beams and the proximity of the PA beam from the
patient’s body to isocenter being 11.67 cm compared to the lateral fields’ depths of
19.63 cm (right lateral (RL)) and 19.68 cm (left lateral (LL)).
o Plan #3’s global maximum dose is 114.9%, cooler compared to plans #1 and #2 because
the addition of lateral fields and equal weighting improved the balance of the dose
distribution.
o In this plan, 49.13% of the PTV is receiving 100% of the dose while 96.79% is receiving
90%. The 100% is especially notable on patient’s lateral aspects where there is no region
of field overlap.
o The 30% and 50% IDLs do not extend into the patient’s anterior aspect and are more
confined to the treatment area.
 Where is the hot spot and what is it?
o The hot spot is located at a depth of 4.94 cm from the patient’s posterior skin surface
where the beam enters, 14.05 cm from the patient’s right lateral aspect, slightly
posterior within the field (8.95 cm superior to inferior field edge).
o Global maximum dose of 114.9% (5170.7 cGy)
  What do you think creates the hot spot in this location?
o The hot spot is at a depth of 4.94 cm from the patient’s posterior skin surface, 14.05 cm
from the right lateral skin surface because that is the location of overlap between the
three fields. The hot spot is in proximity of the PA beam from the patient’s body to
isocenter, located 11.67 cm from the patient’s posterior skin surface.

Plan 4: Increase the energy of all 3 fields and calculate the dose.

 Describe how this change in energy impacted the isodose distribution.

 Volume of 110% at 678.12 cc, 62.20% and 99.93% of the PTV receiving 100%
and 90% of the dose respectively, because plan #3 has a lower Dmax compared
to plan #4. For a 6 MV energy to reach 100% to isocenter, the monitor units
(MUs) in plan #3 were higher than in plan #4.
 Plan #3

Field ID Field Weight Gantry Rtn MU

01 33.3% 180° 75
02 33.3% 90° 101
 03 33.3% 270° 100
 Plan #4

Field ID Field Weight Gantry Rtn MU

01 33.3% 180° 67
02 33.3% 90° 83
03 33.3% 270° 82

o As a result, due to the difference in energies, plan #4 has a lower global maximum dose
of 114.1% (5141.1 cGy) and less 100% present on the peripheries.
o Greater penetrating power compared to plan #3 as evidenced by 99.9% of the PTV
receiving 90% of the prescribed dose because PDD increases with beam energy, and
higher energies deliver a higher-percentage depth dose.
 In your own words, summarize the benefits of using a multi-field planning approach (refer to
Khans ch 11.5B).
o A multi-field planning approach allows for the improvement of homogeneity within the
treatment area along with greater tumor coverage and lesser normal tissue coverage,
increasing the ratio of the tumor dose to the normal tissue dose. 1
 Compared to your single field in plan 2, what percent of the PTV is now receiving 100% of the
prescription dose?
o Plan #4 (triangle): 62.20% of the PTV volume is receiving 100% of the prescription dose.
o Plan #2 (square): 55.10% of the PTV volume is receiving 100% of the prescription dose.

Plan 5: Using your 3 high energy fields from plan 4, adjust the field weights until you are satisfied with
the isodose distribution.
  What was the final weighting choice for each field?
o PA: 26.6%
o Right lateral (RL): 36.7%
o Left lateral (LL): 36.7%
 What was your rationale behind your final field weight?
o With the goal of reducing the global maximum dose and 110% volume, the weighting of
the beams were adjusted gradually to ensure balance of the max dose of each slice
within the treated area. Ultimately, the posterior beam dose contribution was reduced
from 33.3% to 26.6% and 3.4% was added to each lateral field to maintain the total
100% to isocenter. This shifted the 90% and 100% to the periphery but in exchange the
goal was achieved because plan #5 has a lower global maximum dose of 112.1% (5043.3
cGy) and the volume of 110% is smaller at 204.21 cc

Plan 6: Insert a wedge on each lateral field. Continue to add thicker wedges on both lateral fields until
you are satisfied with your final isodose distribution. Note: when you replace a wedge on the left,
replace it with the same wedge angle on the right. Also, if you desire to adjust the field weights after
wedge additions, go ahead and do so.
 What final wedge angle and orientation did you choose? To define the wedge orientation,
describe it in relation to the patient. (e.g., Heel towards anterior of patient, heel towards head
of patient…)

Field Gantry Collimator Wedge angle IN/OUT

rotation rotation
LL 90° 90° 45° IN
RL 270° 90° 45° OUT
 o Left EDW: heel towards posterior of patient and toe towards anterior of patient.
o Right EDW: heel towards posterior of patient and toe towards anterior of patient.
 How did the addition of wedges change the isodose distribution? Include a screen shot
(including axial and coronal) of the isodose distribution before and after the wedge placement
using a plan evaluation/comparison view.

o  Field weights were adjusted PA = 50.7%, LL = 24.6%, RL = 24.7% to ensure the 100% was
distributed throughout the field. Wedges and enhanced dynamic wedges (EDWs) are
beam-modifying devices. In this scenario, I’ve used the EDW in both lateral fields to
decrease the intensity of the beam across the field resulting in the tilt of the isodose
curves and improving the dose distribution. The 100% now covers well in the anterior
treatment area while reducing the posterior dose that was once covered by a large
volume of 110%. As a result, plan #6 has a higher (by .1%) global maximum dose of
112.2%, the volume of 110% is smaller at 20.39 cc, and 90% encompasses the treatment
area without extending to the peripheries. 
 According to Khan, what is the minimum distance a wedge or absorbed should be placed from
the patient’s skin surface in order to keep the skin dose below 50% of the Dmax? (Refer to Khan,
5th ed, Ch. 11.4)
o A distance of at least 15 cm is required between any wedge or absorber in the beam and
the patient’s skin surface to keep the skin dose below 50% of the Dmax. 1 If this distance
requirement is not met, the skin-sparing effect of the megavoltage photon beam will be
ruined by the electron contamination created by the absorber facing the surface. 1

Plan #7: Insert an AP field with a 1 cm margin around the PTV. Remove any wedges that may have been
used. Calculate the four fields. At your discretion, adjust the weighting and/or energy of the fields, and,
if wedges will be used, determine which angle is best. Normalize your final plan so that 95% of the PTV is
receiving 100% of the dose. Discuss your plan rationale with your preceptor and adjust it based on their
input.

 What energy did you decide on and why?

o 15 MV energy applied to four fields because for higher energy beams the Dmax point
lies deeper into the tissue, so higher doses can be delivered to deep tumors without
exceeding skin tolerance due to the higher PDD at the tumor and lower surface dose at
skin. In this scenario, the isocenter is located at a depth of 11.85 cm from the patient’s
 posterior surface (PA beam), 19.46 cm from the patient’s right lateral surface (RL beam),
19.70 cm from the patient’s left lateral surface (LL beam) and 17.19 cm from the
patient’s anterior surface (AP beam). The Dmax of a 6 MV beam is 1.5 cm in a water
phantom compared to the 3 cm Dmax of a 15 MV beam.
 What is the final weighting of your plan?
o Anterior-Posterior (AP): 25%
o PA: 30.1%
o Right lateral (RL): 23.4%
o Left lateral (LL): 21.5%
 Did you use wedges? Why or why not?
o Wedges were unnecessary in this scenario because the AP/PA and RL/LL parallel-
opposed field pairs provided a balanced dose distribution to begin with; the 100%, 90%
and 70% were equally balanced within the treatment area. Thus, adjusting the field
weights was sufficient to further improve the balance and coverage.
 Where is the region of maximum dose (“hot spot”) and what is it?
o The Global maximum dose of 107.5%% is located at a depth of 7.64 cm in the patient’s
anterior aspect and inferior of the field where the beam is entering, favoring the
patient’s left side.

 What is the purpose of normalizing plans?

 o The purpose of normalizing can vary depending on the plan. It’s an action that tells the
TPS to scale the entire Dose-Volume Histogram (DVH) to a higher or lower dose. A plan
can be normalized to increase or decrease the dose to the PTV or organs at risk (OAR).
However, it will simultaneously increase or decrease dose to the OAR or PTV making it
impossible to independently scale to gain an advantage on one structure over another.
 What impact did you see after normalization? Why? Include a screenshot (axial and coronal) of
the isodose distribution before and after applying normalization using a plan
evaluation/comparison view.
 o Before normalizing, 94.12% of the PTV was receiving 100% of the prescription dose and
the plan had a global maximum dose value of 107.2% (4821.8 cGy). After normalizing
95% of the PTV to receiving 100% of the dose, the global maximum dose increased to
107.5% (4835.6 cGy) and 95% of the PTV is now receiving 100% of the dose.
 Embed a screen cap of your final plan’s isodose distributions in the axial, sagittal and coronal
views. Show the PTV and any OAR.
  Include a final DVH. Be sure to include clear labels on each image.

 List typical organs at risk, critical planning objectives, and the achieved outcome. Provide a
reference for planning objectives.

Organ at Risk (OAR) Planning Objective Objective Outcome Objective Met (Y/N)
(Max dose)
Bowel Space TD5/5 Volume 3/3: Max dose: 4789.5 cGy
4500-5000cGy2 Y
 
Max dose: <50GyRTOG
 08223

Bladder TD5/5 Volume 3/3: Max dose: 4720.1 cGy

6500cGy2
 
15% Volume<80Gy
RTOG 01264
25% Volume<75Gy Y
RTOG 01264
35% Volume<70Gy
RTOG 01264 
50% Volume<65Gy
RTOG 01264 

Femurs TD5/5 Volume 3/3: Max dose: 4654.5 cGy

5200cGy2
 
Max dose: <50Gy RTOG Y
08223

Rectum TD5/5 Volume 3/3: Max dose: 4718.6 cGy

6000cGy2
 
15% Volume<75Gy
RTOG 01264
25% Volume<70Gy
RTOG 01264 Y
35% Volume<65Gy
RTOG 01264
50% Volume<60Gy
RTOG 01264

References

1. Khan, FM. The Physics of Radiation Therapy. 6th ed. Philadelphia, PA: Lippincott Williams &
Wilkins; 2019.
2. Emami B, Lyman J, Brown A, et al. Tolerance of Normal Tissue to Therapeutic Irradiation. Int. J.
Radiat Oncol Biol Physhttps://www.redjournal.org/article/0360-3016(91)90171-Y/pdf. Accessed
February 15, 2023. 
3. Hong TS, Maughan J, Garofalo MC, et al. NRG Oncology Radiation Therapy Oncology Group
0822: A phase 11 study of preoperative chemoradiotherapy utilizing intensity modulated
radiation therapy (IMRT) in 1eombination with capecitabine and oxaliplatin for patients with
locally advanced rectal cancer. Int J Radiat Oncol Biol Phys. 2015;93(1):29-36.
doi:10.1016/j.ijrobp.2015.05.005 
4. Bruner DW, Hunt D, Michalski J, et al. Preliminary Patient Reported Outcomes Analysis of 3DCRT
versus lMiRT on the High Dose Am1 of the Radiation Therapy Oncology Group (RTOG) 0126
Prostate Cancer Trial. Cancer. 2015; 121 ( 14):2422-2430. doi: I 0.1002/cncr.29362